Bulbous Nasal Tip Repair

Posted on October 18, 2017

One of the most frequent type of nasal tip deformities I encounter is often simply called a ‘bulbous’ nose. This term refers to a nose that has the appearance of a ball on the end of it. This case example highlights management of this type of nose deformity with real before and after photos.

This patient presented to me complaining of a bulbous looking nose. In addition, she noted difficulty breathing through her nose. Her frontal photo is shown here. You can readily see that the tip of her nose appears quite bulbous. More specifically, she has too much cartilage fullness as shown in the adjacent diagram by the green shaded area. But she is lacking sufficient cartilage in the areas indicated by the red arrows. In fact, this is why her nose appears so bulbous – because the distribution of cartilage is so abnormal. And this also explains why her nose does not function as well as it should – because the cartilage deficient areas (red arrows) are critical in providing proper support of the nostril rim. When this cartilage support is not sufficient, as is the case here, patients will have collapse or pinching of the nose as they breathe in each time. So this patient had dual indications for undergoing reconstructive nose surgery – not only did she have an undesirable nasal appearance, she also had trouble breathing through the nose.

Bulbous Nose Tip Rhinoplasty

I ended up recommending an open rhinoplasty approach to help reconstruct her nose. In the adjacent photo you can see what her anatomy looked like upon lifting the skin up. This oblique angle offers one of the better perspectives when it comes to demonstrating why her nose appears so bulbous.

The whitish colored structures are the tip cartilages – called the lower lateral cartilages – that essentially make up the shape of the nasal tip. In her case, you can see just how arched the cartilage really is as it courses up and over the nostril opening. This is not too surprising given what we saw in her preoperative photographs. You can also more readily appreciate how she is lacking cartilage support out to the side of the nostril (corresponding to the red arrow in the previous photograph). Some rhinoplasty surgeons will refer to this type of anatomical problem as cephalic orientation of the lower lateral cartilages. This is a fancy rhinoplasty surgery term that simply means the cartilage is oriented in an up and down, or vertical, direction as opposed to being oriented in a more horizontal direction. With such a highly curved and arching nostril cartilage, there is no wonder that her nose appeared bulbous on the frontal view! Now you know what this type of problem looks like under the hood – so to speak.

In order to correct a bulbous nose deformity like this, the entire tip complex has to be completely reshaped. And this is where the open rhinoplasty approach has a huge advantage over a closed rhinoplasty approach – because exposure to the offending cartilage is unparalleled. In this case, I started out by ‘weakening’ the highly arched segment by trimming the cartilage – but only conservatively. My goal was to try and preserve as much of her native cartilage for support. After all, the goal was to try and improve her nostril support to help her dysfunctional nasal breathing. I then took cartilage from inside of her nose – specifically from the septum – and repurposed this cartilage as several grafts. This means that the septal cartilage was used as a ‘splint’ to reshape the unwanted curvature in her native cartilage. In the process of doing this, the entire tip cartilage complex was reoriented to go out more horizontally away from the tip of the nose – thereby reducing the vertical orientation it once had. The end result was a nasal tip that was now much less arched and curved. In fact, the lower lateral cartilage complex was made to be much flatter and angular as seen in the adjacent photo. Comparing the intraoperative changes before and after, you can see for yourself just how significant these alterations were in surgery. It almost appears that they are two different patients! But, in fact, it is the same nose – just without the bulbous, curved tip cartilage.

If you look more closely at the nostril opening, you can also readily appreciate how this has changed from the reconstructive rhinoplasty. Her tip cartilage is now extending out to the side, which helps provide her with more support – and, therefore, improved breathing. If you were to meet this patient in person, she will tell you that her life has changed dramatically in terms of being able to breathe properly through her nose.

Bulbous Nasal Tip Photos

Here are her before and after photos showing the overall changes made to the tip complex as a result of the rhinoplasty surgery. If you look critically at the photo comparisons, you will see just how different her nose is now. In particular, she has a lot less fullness above the tip (less bulbous) and proper contouring out to the sides of the tip. The latter changes translate into improved support for breathing. From the bottom, or base, view you can also see how the overall shape of the tip now approximates more of a ‘soft triangle’ as opposed to the trapezoidal shape she had previously.

San Diego Bulbous Nose Consult

If you have a bulbous nose deformity and are interested in reconstructive surgery to repair this problem, contact our office today to schedule a personalized consult with Dr. Hilinski – one of the nation’s leading experts in cosmetic and reconstructive rhinoplasty.

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